Evaluating Social Work Services in Nursing Homes: Toward Quality

Institute for the Advancement of Social Work Research

Betsy Vourlekis

Joan Levy Zlotnik

Kelsey Simons

Connecting policy, practice, and education through

advancement of research

A Report to the Profession and Blueprint for Action

Evaluating Social Work Services in Nursing Homes:

Toward Quality Psychosocial Care and Its Measurement

Copyright © 2005 by the Institute for the Advancement of Social Work Research. All rights reserved.750 First Street, NE, Suite 700Washington, DC [email protected]

www.iaswresearch.org

Project undertaken by the Institute for the Advancement of Social Work Research in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work, Boston University School of Social Work and funded in part by a grant to the Institute for the Advancement of Social Work Research from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (1R13HS015505-01).

CONTENTS

ii Foreword

iii Executive Summary

1 Introduction

2 Background

3 Summary Findings

8 Conclusion and References

10 Appendix A. Conference Agenda

12 Appendix B. Summaries of Presentations

27 Appendix C. Presenter and Discussant Biographies

30 Appendix D. Conference Participants

33 Appendix E. Internet Resources

Joan Levy Zlotnik, PhD, ACSW

Executive Director


April 2005

FOREWORD

This Report to the Profession and Blueprint for Action is the result of the vision and hard work of several people over a more than 2-year period. The Institute for the Advancement of Social Work Research (IASWR), a private, non-profit organization in Washington, DC, took on this initiative in keeping with our mission to advance the knowledge base of social work practice and to promote the use of research to improve practice, program development, and policy. How-ever, it has its roots in the hopes and goals that many of us had for the nursing home reform legislation that passed in 1987. It was the vision of the legislation that each nursing home resident would receive the quality of care and have the quality of life to “attain or maintain their highest prac-ticable physical, mental and psychosocial well-being.” The December 2004 conference Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement provided an opportunity to take stock of what has been accomplished, e.g., standardized assessments and assessment tools, commitment to interdisciplinary prac-tice, increased attention to quality improvement, a growing body of quality-of-life research, and the development of the culture change movement. It also provided an opportunity to outline a range of ways that the social work role in nurs-ing homes could be more fully measured and implement-ed, to improve quality of care and quality of life.

It was an exciting endeavor to bring together a group of practitioners, educators, researchers, advocates, consum-ers, and policy makers to address an area that previously had not been so fully explored: social work contributions to quality psychosocial care in nursing homes. It was an interdisciplinary endeavor, with collaborators from federal agencies, national organizations, and academia. The Agen-cy for Healthcare Research and Quality (AHRQ) of the De-partment of Health and Human Services (DHHS) awarded a conference grant to IASWR, and I want to thank AHRQ staff Charlotte Mullican and Judy Sangl for their input and guidance. I also want to thank Bob Connolly from the DHHS Centers for Medicare and Medicaid Services for his input, feedback, and guidance. IASWR is grateful to the Institute for Geriatric Social Work (IGSW), Boston Uni-versity School of Social Work (funded by Atlantic Philan-thropies) and IGSW’s director, Scott Geron, in providing support for practitioners to attend the symposium and the development of an issue brief “Blueprint for Measuring So-cial Work’s Contribution to Psychosocial Care in Nursing

Homes: Results of a National Conference,” Winter 2005, www.bu.edu/igsw) that summarizes the background infor-mation and recommendations from the meeting.

IASWR’s partnership with the University of Maryland was the key to being able to undertake the grant writing as well as the planning, implementing, and follow-up to the symposium. Betsy Vourlekis provided expertise, knowl-edge, and conceptual thinking in the development of the grant, in organizing of the symposium, and in the develop-ment of this Blueprint for Action. Kelsey Simons was able to use her nursing home experience and her own develop-ing research career toward a new direction by serving as a graduate assistant to assist in writing the grant and devel-oping the background “Briefing Book” (available at www.iaswresearch.org), the literature review, and the summaries of the presentations. Each of the symposium speakers and discussants shared important expertise and perspective to stimulate rich discussion and assist in constructing an agen-da for action. IASWR staff (Barbara Solt, senior program associate, and Brenda Bustos, administrative coordinator) played a key role in making this happen and Rebecca Toni, IASWR’s intern, organized materials and the key web re-sources that will be useful to the field.

This Blueprint should be useful, not only to those who at-tended the symposium, but also to individual practitioners, researchers, administrators, educators, and consultants. It is also intended to be a source of information and action for national professional and provider organizations and advocacy groups, as well as to foundations, policy analysts, and funders. There are broad arrays of actions that can be taken that will weave a path to better outcomes for those who live and work in nursing homes. These recommenda-tions can also be useful in the development of guidelines and evaluation tools for other long–term care settings, such as assisted living, an expanding residential option for meet-ing the needs of our aging society.

ii

Despite improvements in the quality of nursing home care since the passage of the Nursing Home Reform Act of 1987 (NHRA), concerns persist with regards to both the quality of care, including psychosocial care, and the quality of life for nursing home residents (Wiener, 2003). Social work ser-vices, a federally mandated provision, are a key contributor to meeting residents’ psychosocial needs yet current federal and state regulatory processes do not routinely assess more than the structural absence or presence of a social service provider. The contributions and impact of the social worker are not systematically examined or assessed. In December 2004, the Institute for the Advancement of Social Work Research (IASWR), in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work at Boston University, and supported by the Department of Health and Human Services Agency for Healthcare Research and Quality (1R13HS015505-01), convened a national working conference to examine the provision of social work services and the relationship of the social worker’s role and functions to improving psychoso-cial care in the nursing home.

The meeting brought together practitioners, research-ers, policy makers, and educators across several disciplines to address three major aims:

1. Clarify and specify realizable role, function, and inter-vention expectations for social work personnel along with their operational links to resident and facility psy-chosocial care and quality of life outcomes;

2. Examine existing and potential measurement approach-es for increased accountability (in process and out-comes) and quality-of-care enhancement of social work services and psychosocial care/quality of life (QOL) at the home, survey, and national data base levels;

3. Recommend strategies to improve the monitoring and measurement of quality psychosocial care and of social work services that address resident and family mem-bers’ psychosocial needs.

In preparation for the symposium an extensive briefing book (available at www.iaswresearch.org) was developed to provide background information to the participants

EXECUTIVE SUMMARY

so they would come prepared to address the symposium’s aims. The presentations and discussions led to a set of rec-ommended action steps that can guide professional social workers, funders, provider organizations, professional asso-ciations, educators, regulators, and researchers. Highlights of recommended action steps are described below:

Specify practice interventions and develop studies to test the core domains of social work practice in nursing homes.

• Examine best practice facilities (as defined through high performance on national data base quality indica-tors or those who are pioneering culture transforma-tion approaches) for further study of traditional and nontraditional social work involvement, roles, and practices.

• Conduct systematic reviews of the relevant evidence base and develop practice protocols and guidelines for high prevalence, high-priority practice processes.

• Develop/identify practitioner-friendly practice evalu-ation tools for facility-level applied research (qual-ity monitoring and improvement), and promote their wider dissemination and use.

• Encourage field practica that involve nursing homes, providing opportunity for practice–academic partner-ships to build the empirical base for practice.

• Contact and collaborate with academic nursing and medical colleagues focused on nursing home practice and research to identify common areas of concern, such as interdisciplinary team functioning and care planning, diagnosis of emotional and behavioral disor-ders, end-of-life care.

• Identify, examine, and promote successful models of complementary and collaborative psychosocial care provision by nurses and social workers.

• Continue to build the statistical trail for professional social work in nursing homes through examining the extent of deployment of professionally prepared per-sonnel in both staff and contractual capacities.

What is culture change? Culture change in long-term care is an ongoing transformation based on person-directed values that restores control to elders and those who work closest with them. This transformation includes changing core values, choices about the organi-zation of time and space, relationships, language, rules, objects used in every-day life, rituals, contact with nature, and resource alloca-tion. This definition is from the Pioneer Network (www.pioneernetwork.net).

iii

Enhance research endeavors related to nursing home practice and outcomes.

• Convene a small working group of social work research-ers and practitioners to develop a detailed research agenda for professional practice in nursing homes.

• Pursue opportunities for collaboration with large-scale multidisciplinary research efforts in NHs where a so-cial work practice component could be conceptualized and tested as part of the overall effort (e.g. depression-care improvement; end-of-life care improvement).

• Undertake research using existing Centers for Medi-care and Medicaid Services (CMS) measures and federal and state data bases (for example numbers of depressed residents as a mental health outcome) to study social work practice.

• Use reliable, state-of-the-art QOL measures (e.g., Kane, 2003) for intervention research on social work practice at both the resident (micro) and overall facility (macro) levels.

• Conduct comparison analyses of social work practice in “culturally transformed” environments versus “tra-ditional” homes.

• Conduct needs assessment research on the true extent of unmet psychosocial need in NHs and identify the most prevalent barriers.

Increase social work involvement in federal processes and initiatives and national reform efforts recognizing that social work’s contribution to care rests in part on increasing the visibility of social work’s expertise and viewpoint in the wider deliberations and conversations that surround policy decisions, including those promoted by the nursing home industry.

• Create a national virtual network of social work nurs-ing home experts to improve the visibility of existing NH practitioner networks and social work research-ers, strengthen their collaboration, and facilitate their identification and involvement in CMS initiatives, in-cluding modifications to care-planning protocols, com-puterized assessment tools, and enhanced surveyor guidelines for assessing adequacy of psychosocial care and social services.

• Strengthen organizational social work involvement in nursing home practice improvement (e.g. NASW, As-

sociation for Gerontology Education in Social Work) at CMS, AHRQ, the Department of Veteran’s Affairs, and the Health Resources and Services Administra-tion, by providing expertise to national advisory com-mittees and panels, and other national forums and meetings.

• Create a National Social Work Center on Long Term Care that would be a clear place of focus and consoli-dation for a range of professional information and ef-fort and that would provide social work leadership for national strategies to promote culture transformation and stronger federal requirements for QOL that have the potential to improve nursing home care in funda-mental ways.

Conclusion

According to the Centers for Medicare and Medicaid Ser-vices, there are currently close to 17,000 nursing homes in the United States. The challenges of strengthening so-cial work’s contribution to improving care arise on many fronts. There is a continuing need to ensure that geronto-logical practice options, including nursing home practice, are attractive to students. University–field collaborations can be the foundation for practice enhancement efforts in developing practice guidelines, evaluation tools, and con-ducting effectiveness research.

Partnership strategies and interdisciplinary collabo-ration are also crucial, and some initiatives will require funding, whether from foundations or government. Other disciplines, such as nursing, share social work’s workforce and quality-of-life concerns and can be allies. Social work’s practitioners and educators must connect and contribute to the programs and initiatives of organizations represent-ing the nursing home industry as well as those represent-ing consumers. Federal agencies and social workers within these agencies can be important partners in the profession’s efforts.

The path and cause of cultural transformation of “nurs-ing homes” is rooted in the centrality and defining nature of resident and family perceptions of the quality of their psychosocial reality. The profession’s contribution to care improvement must be forward looking, and demonstrate a courage to undertake the necessary strengthening of its effectiveness in carrying out the fundamental tasks of psy-chosocial service provision.

iv

1

of social work services is a priority responsibility of the pro-fession. Furthermore, social work expertise and worldview can make important contributions to research on nursing home care and quality of life. In studying provision of psy-chosocial care, social work’s person–environment perspec-tive is especially important in investigating the impact of both resident-level interventions and home-as-a-whole in-terventions and their interactions. Social work’s expertise in group and family process adds a critical dimension to both psychosocial care provision and effectiveness research that can significantly expand the understanding of what contributes to highest quality care.

In deliberations over 2 days participants at the Decem-ber 2004 conference addressed the following three aims:

1. Clarify and specify realizable role, function and inter-vention expectations for social work personnel along with their operational links to resident and facility psy-chosocial care and quality of life outcomes;

2. Examine existing and potential measurement approach-es for increased accountability (in process and out-comes) and quality-of-care enhancement of social work services and psychosocial care/quality-of-life (QOL) at the home, survey, and national data base levels;

3. Recommend strategies to improve the monitoring and measurement of quality psychosocial care and of social work services that address resident and family mem-bers’ psychosocial needs.

The following sections present relevant background in-formation and summarize key ideas, issues, and resources that emerged from the meeting for each of the three con-ference aims. The information has been distilled from for-mal presentations by invited speakers, remarks by invited discussants, comments and questions from participants, small group deliberations, and the final group-as-a-whole discussion that concluded the conference. The conference agenda (Appendix A), summaries of presentations (Ap-pendix B), presenter and discussant biographies (Appen-dix C), list of participants (Appendix D), and resource list (Appendix E) provide additional information. An exten-sive briefing book that was provided to the participants prior to the meeting is available on the IASWR website at www.iaswresearch.org.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement

A REPORT TO THE PROFESSION AND BLUEPRINT FOR ACTION

Introduction

Despite improvements in the quality of nursing home care since the passage of the Nursing Home Reform Act of 1987 (NHRA), concerns persist with regards to both the quality of care, including psychosocial care, and the quality of life for nursing home residents (Wiener, 2003). A 2003 federal Department of Health and Human Services (DHHS) Of-fice of Inspector General (OIG) scrutiny of psychosocial care revealed that 39% of reviewed resident charts had in-adequate plans and 46% with care plans did not receive the planned services. The reasons that residents do not get their needs met are not known because there is no compre-hensive approach to monitoring and measuring psychoso-cial care and quality of life in nursing homes in the United States. This lack is an interdisciplinary and inter-organiza-tional concern that requires the combined efforts of regu-lators, administrators and providers charged with quality monitoring and measurement in the nursing home, and key research and practitioner expertise in the area of psy-chosocial care. To this end the Institute for Advancement of Social Work Research (IASWR), in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work at Boston University, and supported by the federal government’s Agency for Healthcare Research and Quality (1R13HS015505-01), convened a national working conference in December 2004: Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement.

The meeting focused on the provision of social services and the relationship of the social worker’s role and func-tions to improving psychosocial care in the nursing home. It is evident that psychosocial care is far broader than social services/social work, and that all providers as well as the overall home environment play a part. It is also the case that social workers contribute to care in the home through a wide range of roles beyond that of social service provider. However, as a federally mandated and regulated compo-nent of nursing home care, social services provided by pro-fessionally prepared social workers can be clearly identified and examined. This therefore can lead to more effective practice monitoring and evaluation measurement efforts.

Enhancing and demonstrating the quality and impact

2 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement

Background

The Need

Social work practice in nursing homes faces the imperative for evidence-based practice at the same time as consumers and regulators search for better approaches to delivering and assuring quality care. Yet even the necessary national statistical profile for the profession’s presence in nursing home care is lacking. Current federal and state regulatory processes do not routinely assess more than the structural absence or presence of a social service provider. The con-tributions and impact of the social worker are not system-atically examined nor assessed in survey and certification processes, leaving no visible track record. The interplay of several factors currently constricts the potential to stan-dardize, measure, and improve the contribution made by the discipline of social work, limiting accountability, and with it, opportunities for higher quality care. These con-straints include:

• Social service staffing inconsistencies (to which cur-rent federal regulations contribute) dilute expectations for a consistent set of services.

• Professional practice standards are broadly inclusive of role and processes, but are not supported with proto-cols and guidelines that would promote performance consistency and its measurement.

• The absence of conceptual and operational links be-tween social work psychosocial care processes in nurs-ing homes and surveyed outcomes leads to invisibility and diminished expectations.

• There are few measurement strategies (internal or ex-ternal to the nursing home) to routinely monitor social work processes for results.

• A rudimentary professional research base has yet to clearly demonstrate intervention effectiveness for so-cial work practice in the nursing home.

Despite these realities, a “critical mass” of professional NH social workers exists—it is estimated that 60–66% of social service staff have degrees in social work (Kruzich & Powell, 1995; Quam & Whitford, 1992; Simons, 2005; Vinton, Mazza, & Kim, 1998; Vourlekis, Bakke-Friedland, & Zlotnik, 1995)—providing a consistent set of services that can be the basis of more systematic monitoring and mea-surement and intervention research. A feasible blueprint needs to be crafted to guide the development of evidence for a set of consistently implemented social work roles and functions, guidelines for expected “best practice” in those

roles, and demonstration of the link between practice and valued resident and home-as-a-whole outcomes.

Federal Regulation and Social Work

Current federal NH regulations (CMS, 1989, 42 CFR 483.15) require all nursing facilities to identify the medi-cally related social and emotional (psychosocial) needs of each resident and develop a plan to assist each resident in adjusting to the social and emotional aspects of his or her illness, treatment, and stay in the nursing home. To-wards this end, the NHRA requires all nursing facilities to provide social services, but additionally requires nursing homes over 120 beds to employ a ful- time social worker with at least a bachelor’s degree in social work or “simi-lar professional qualifications.” Facilities with 120 beds or fewer must still provide social services but do not need to have a full time social worker on staff. The staffing arrange-ment and qualifications are left unspecified by regulation for these homes. Although NH regulations require facili-ties to use licensed personnel, this obligation has not been applied or enforced in the case of social work.

Psychosocial Care and Social Work

The term “psychosocial” describes a constellation of so-cial and emotional needs and the care given to meet them. Psychosocial concerns in nursing homes from the perspec-tive of the social work provider include recognition, diag-nosis, and treatment of mental health disorders such as depression, anxiety, dementia, and delirium, all measured by the MDS (federally mandated Minimum Data Set com-pleted for each resident). Studies document the extent of NH resident mental health needs (Burns et al., 1993; Castle & Shea, 1997; Meeks, Jones, Tikhtman, & LaTo-urette, 2000), and problems in mental health care delivery, including ineffective diagnosis, lack of follow-through with needed services, and over-reliance on pharmacological in-terventions, including over-medication, in lieu of psycho-social in-home interventions (AGS & AAGP, 2003; Shea, Russo & Smyer, 2000; Snowden, Piacitelli & Koepsell, 1998).

In addition, psychosocial care addresses a range of issues with more obvious social dimensions, including loss of re-lationships, loss of personal control and identity, adjust-ment to the facility, continuity of care, and end-of-life care. Support to the resident’s family, including involvement in the resident’s care and attention to their concerns and needs forms another component of psychosocial care. A broader but related concept is quality of life (QOL) focused

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 3

on the perspective of the residents themselves with respect to their total living experience in the home, not just their medical care. Kane and colleagues (2003) delineated 11 domains for QOL, including autonomy, functional com-petence, privacy, dignity, meaningful activity, individuality, enjoyment, security, relationships, spiritual well-being, and comfort. QOL is increasingly viewed as an essential out-come of good NHs, and the contributions of social work processes in the home to this outcome are assumed, but unproven. Also of concern are how inhospitable nursing home environments and routines can be for the well-being of residents, leading to comprehensive considerations of total “culture transformation” (Fagan, Williams, & Burger, 1997). The social work contribution to psychosocial care potentially focuses on aspects of the home environment that affect all residents.

Summary Findings

The following provides an overview of the key issues ad-dressed by the presentations and discussions at the sympo-sium, which were organized by the three aims stated above. The summary findings include a specification of suggested recommendations and actions steps.

Aim #1: Clarify and specify role, function, and intervention expectations for social work personnel and link these operationally to resident and facility psychosocial care and QOL outcomes.

• Social work roles in nursing homes are varied, includ-ing staff social service provider, member and psychoso-cial advisor to the interdisciplinary team, social work consultant (an external provider to a home that is without a “qualified” social service professional), and psychotherapist (external provider of mental health services to a resident under Medicare Part B). Fur-thermore, social workers function as administrators, unit heads, and department directors. There are social worker home administrators and owners of nursing homes. The extent of social work involvement in many of these roles is unknown. In addition, the potential ex-ists for new social work roles within reconfiguring care environments that are responsive to the culture change

movement. While recognizing the actual and possible diverse social work roles, the December 2004 meeting focused primarily on the roles and functions of staff social work provider of social services and member of the interdisciplinary care team.

• Improvement in practice evaluation and more rigor-ous practice effectiveness studies of social work service provision depend on the consistent performance of a set of social work functions, within and across set-tings. A convergence of agreement emerges from the comparison of empirical studies (Vourlekis et al., 1995; Vourlekis, Gelfand, & Greene, 1992;), practice guidelines (National Association of Social Workers [NASW], 1993, 2003; Department of Veterans Affairs, 2001), and a recent statement of practice competencies (Rosen, Zlotnik, & Singer, 2002), revealing six broad functional areas (Greene, 2004) that form the core of social work practice in the nursing home setting.

1. Conduct psychosocial assessments through in-formation gathering (this would include mental health and involve the completion of related por-tions of the MDS 2.0 and related Resident Assess-ment Protocols).

2. Provide psychosocial interventions that enhance coping skills for residents and their families (vari-ety of treatment modalities including, but not lim-ited to crisis intervention, mediation, and group, individual, and family counseling).

3. Assist with long-term care transitions through case management (linkages and referrals and admis-sions, discharge, etc.).

4. Participate in care planning.

5. Collaborate with the nursing home team (includ-ing consultation re: psychosocial issues).

6. Attend to individualized decision-making (elicit-ing and facilitating resident choice and preference, including end-of-life decisions).

• Further specification of the actual and most appro-priate scope, tasks, strategies, and procedures used in implementing these six functions is needed to map ac-countability for a consistent set of services across facili-ties. For example, specification of a “best practice” or guideline-based approach to mental health screening

What is culture change? Culture change in long-term care is an ongoing transformation based on person-directed values that restores control to elders and those who work closest with them. This transformation includes changing core values, choices about the organi-zation of time and space, relationships, language, rules, objects used in every-day life, rituals, contact with nature, and resource alloca-tion. This definition is from the Pioneer Network (www.pioneernetwork.net).


and diagnosis, prior to completion of the MDS, would be necessary to measure the social worker’s contribu-tion to improved accuracy in MDS or in efforts to dis-tinguish between residents’ reactions to poor quality NH environments versus true depression. What are the psychosocial interventions most commonly provid-ed by social workers to enhance coping (for example, orientation sessions for residents and family members) or to facilitate resident choice?

• Specification of interventions within the six functional domains that are presumed to influence critical out-comes (process–outcome links) can be done at the level of an individual home as part of an overall facil-ity internal approach to quality improvement and to “quantify” the value added of the social service provid-er. Demonstrating “worth” to administrators requires linking interventions to problem reduction, such as fewer family complaints, less demand on staff from agi-tated patients, and higher bed occupancy rates.

• The OIG report (cited above) as well as other data sources point to a significant gap between psychosocial needs identification and actions actually taken. The social work provider should be central to (1) identifica-tion of psychosocial needs (assessment function); and (2) specification of services/actions (care planning), even when not responsible for providing all indicated services. Moreover, monitoring by social workers for follow-through of all planned psychosocial services would contribute to identifying barriers and improv-ing accountability in the facility.

• The problems in mental health care delivery in the home are a priority area for social work practice im-provement, including specification of intervention strategies. Prevention activities, non-pharmacological treatments for milder conditions, and follow-through and bridging with external care providers (case manage-ment) for severe disorders are all reasonable functional expectations for staff social workers, highlighting the need for practice guidelines and protocols for these practice functions.

• Research documents multiple care provision/care en-vironment influences on resident self-reported QOL, including many that would be within the functional domains of social work, e.g., social circumstances, un-treated depression, involuntary moves, continuity of care, meaningful activity, maximization of indepen-dence, and fostering relationships (see Kane Summary, Appendix B). However, knowledge and specification of effective interventions, including those of social work-ers, and their optimal “dosage” lags behind the ability to satisfactorily measure QOL outcomes.

Aim #2: Examine existing and potential measurement approaches for increased accountability (in process and outcomes) and quality care enhancement of social work services and psychosocial care/QOL at the home, survey, and national data base levels.

Federal Regulatory Approaches and Initiatives

Existing CMS measures of psychosocial care quality serve as starting points in developing strategies for improve-ment in the measurement and monitoring of psychosocial services, including services provided by social workers. Federal data sources include survey F-tags, RAI (Resident Assessment Instrument) outcome data, and QI (Quality Initiative) outcome measures. While current federal mea-sures are problematic in many ways, and do not currently provide clear-cut connections to social service provision, they are the essential platform for designing workable so-cial work evaluation and measurement approaches.

F-tags are best described as a line of defense against substandard care rather than as indicators of quality care. Tags refer to specific sections of the regulations and, when cited by surveyors, indicate deficient care(out of compliance with regulatory standards) in that area. The six F-tags compiled in the CMS Online Survey Certifica-tion and Reporting (OSCAR) data set currently viewed as most directly related to psychosocial care and social service provisions are as follows:

• Residents’ right to organize and participate in resident groups (F243)

• NH policies that accommodate residents’ needs and preferences (F246)

• NH provides residents with appropriate treatment for mental or psychosocial problems (F319)

• NH ensures that residents do not have avoidable de-cline in their psychosocial functioning (F320)

• NH over 120 beds employs a qualified social worker on a full-time basis (F251)

• NH provides medically-related social services (F250)

Severity of F-tag Deficiency

CMS has underway currently a project to upgrade sur-veyor guidelines for establishing the level of severity of the care deficiency that has been identified in a facility. As a part of the upgrade, evidence concerning psychosocial se-verity (impact of deficient care on psychosocial well-being) as well as medical severity is now being examined so that psychosocial severity can be assessed as a component of any deficiency.


Resident Assessment Instrument

The federally mandated Resident Assessment Instru-ment (RAI), completed for every resident on a regular in-terval, consists of the Minimum Data Set (MDS) and its corresponding Resident Assessment Protocols (RAPs). The RAI is the basis for clinical assessment and care planning in nursing homes, and also serves as an additional set of indicators of quality of care in nursing homes through the monitoring of resident outcomes as described briefly be-low. Social workers, as members of the interdisciplinary team, are typically involved in completing the MDS and RAPs, particularly sections related to cognitive, mood and behavior patterns, psychosocial well-being, and discharge potential (Beaulieu, 2002).

• Concerns persist regarding the ability of the MDS to ac-curately identify residents’ psychosocial problems. The American Geriatrics Society/American Association for Geriatric Psychiatry Consensus Statement (2003) stat-ed that the MDS is not an adequate tool for screening residents with depression and behavioral problems re-lated to dementia. Yet, the MDS is commonly the only screening tool used within facilities to assess for these conditions. Other suggested limitations of current sys-tematic assessment processes include data sources (too little of the resident’s input and perceptions), absence of checks for assessment accuracy, and disconnect be-tween assessment and actions taken (Kane & Kane, 2000). Practitioners at the symposium noted that so-cial work involvement in MDS and care planning is often not “meaningful,” with a reliance on check-lists, computer generated care plans, and an absence of in-terdisciplinary conversation based on a more enriched understanding of individualized psychosocial circum-stances.

• The “engagement” items of MDS could be useful in connection with social work interventions. There are scales available that could provide reliable measures for these items.

• Practitioners do not view current MDS items related to “discharge” as useful. Yet there is a need to link the social work function of transitional care (case manage-ment, discharge planning, community referrals, follow-through on care referrals) to a meaningful measure.

Quality Initiative (QI) Outcome Measures

As part of a more comprehensive quality improvement initiative, CMS has developed a set of quality indicators, based on MDS data, which are used for aggregate and comparison purposes of nursing homes nationally. Data

for the QIs are published on the CMS Nursing Home Compare Website for consumer review (http://www.cms.hhs.gov/quality/nhqi/). Two of the NHQI measures the percentage of residents who have become more depressed or anxious and the percentage of short-stay residents with delirium capture psychosocial constructs. However, these facility-level measures also raise questions concerning the “origin” of the assessed problems to begin with. To what ex-tent are the documented residents’ depression, anxiety, and delirium related to the facility QOL and QOC rather than individual underlying medical and behavioral disorders?

Measuring Quality of Life

Nursing home quality of life has been an important construct of quality improvement efforts and is explicitly addressed in federal regulations. CMS has funded research to improve quantification and measurement of QOL in the nursing home as a necessary precursor to enhance-ments of survey and certification processes or collection of national outcome data. Sampling in 100 NHs across five states, Kane, Kling et al. (2003) and Kane, Bershadsky et al. (2004) measured the outcome of resident QOL in 11 domains. They tested for influences and indicators (aspects of the home or care that may be related) that were associ-ated with better QOL.

Research Findings

Important conclusions from the 5-year QOL Kane and colleagues’ (2003, 2004) study include:

• QOL is multidimensional and subjective and is mea-sured by asking the resident directly, thus allowing for individual and cultural differences.

• QOL could be reliably measured for 60% of NH resi-dents (i.e., they could answer the questions themselves), including many whose MDS data suggested consider-able cognitive impairment.

• Facility level aggregate QOL data showed patterns (gen-erally good or bad across all domains).

• The relationship between many hypothesized indica-tors (care processes, facility structure, etc.) was not demonstrated because of the difficulty of consistency in measurement. This does not mean that these indica-tors have been shown to be irrelevant. Work is needed at the individual facility level to demonstrate relation-ships.

• Having a single room was identified as one structural variable that was related to multiple QOL domains.


QOL and Social Work Research

There are many possible structures and pathways to ex-cellent nursing home care that is characterized by a better quality of life. The feasible and reliable measurement of resident QOL provides social work research with an impor-tant opportunity to link a variety of practice interventions and goals to an outcome that is central to regulatory, policy making, culture-change principles, and consumer-activist efforts to improve care.

Aim # 3: Recommend strategies to improve the monitoring and measurement of quality psychosocial care and of social work services that address resident and family members’ psychosocial needs.

The following provides a set of strategies and recom-mendations for action that can result in enhanced dem-onstration of the outcomes of social work services and the improvement in meeting the psychosocial care needs of residents and their families. Construction of the evidence base to support high quality professional social work prac-tice in nursing homes, and with it, efforts to improve quali-ty of life and care will require labor on several fronts. These needed efforts are complementary, mutually reinforcing, and ask for direction and leadership from different sectors of the professional community. Social work practice, poli-cy, advocacy, and research expertise in nursing home life ranges across a rich landscape of issues. There are several important initiatives underway in the profession with great relevance for nursing home practice and care. However, the profession’s voice and potential contributions are cur-rently limited by the lack of a national structure to provide visibility and focus to nursing home social work services, the absence of regular opportunities for communications and collaborations among professionals and the absence of organized linkages to professional initiatives in this do-main. The recommendations outlined below encompass three areas:

A. Develop practice guidelines and practitioner-friendly practice evaluation tools;

B. Conduct intervention/effectiveness research; and

C. Increase social work involvement in federal measure-ment and quality improvement processes and in na-tional care improvement initiatives.

A. Develop practice guidelines and practice evaluation tools.

This work requires practitioner direction and leadership, in partnership with academic research colleagues. The goal is to connect delineated best practices (processes) in the

six functional domains (outlined above) with federal, state, and Joint Commission on Accreditation of Healthcare Or-ganizations current and evolving measurement approaches in ways that can be measured meaningfully. It involves ap-plied research that can be carried out in just a single facili-ty, but provides the necessary building blocks for systematic investigation of social work across multiple facilities wheth-er for accountability or research on effectiveness.

Recommended actions include the following:

• Convene a working group of practitioners in collabora-tion with academic social work gerontologist(s) to (1) further specify “normative” practice processes in the six domains (see Greene summary, Appendix B); (2) select the highest prevalence and highest priority prac-tice processes for protocol/guideline development; and (3) confirm through further research the validity of the choices. For example, while some assessment processes are already clearly identified and case management processes have been standardized, the interventions that are most typically used to promote individualiza-tion, choice, and preference are unclear.

• Examine best practice facilities (as defined through high performance on national data base quality indica-tors or those who are pioneering culture transforma-tion approaches) for further study of traditional and nontraditional social work involvement, roles, and practices. Of particular interest are social work man-agers and the factors contributing to their achieving positions of leadership.

• Conduct systematic reviews of the relevant evidence base (e.g. best depression screening tools for use with the elderly; ethical and practical pitfalls in working to-ward advance directives; group interventions that pro-mote involvement of the most cognitively impaired; interventions that promote constructive family in-volvement in care) and develop practice protocols and guidelines for high-prevalence, high-priority practice processes.

• Develop/identify practitioner-friendly practice evalu-ation tools for facility-level applied research (quality monitoring and improvement), and promote their wid-er dissemination and use, providing assistance to NH social workers in their use through continuing educa-tion and special workshops.

• Schools with Hartford Funded Geriatric Enrichment Projects or enriched field placements through the Practicum Partnership Program that involve nursing homes should provide leadership for practice–academ-ic partnerships to build the empirical base for practice. The established “partnership” structures offer impor-

A. Develop practice guidelines and practitioner-friendly practice evaluation tools;

B. Conduct intervention/effectiveness research; and

C. Increase social work involvement in federal measure-ment and quality improvement processes and in na-tional care improvement initiatives.


tant opportunities for organized social work interac-tion with other groups to further the applied research agenda. For example,

> Contact and collaborate with federally supported regional Quality Improvement Organizations for technical support in facility-level QI efforts and for increased visibility for social work processes in the home.

> Contact and collaborate with academic nursing and medical colleagues in the nursing home prac-tice and research communities to identify areas of common concern such as interdisciplinary team functioning and care planning, diagnosis of emo-tional and behavioral disorders, and end-of-life care.

• Identify, examine, and promote successful models of complementary and collaborative psychosocial care provision by nurses and social workers.

• Continue to build the statistical trail for professional social work in nursing homes through examining the extent of deployment of professionally prepared per-sonnel in both staff and contractual capacities. The Federal Social Work Workforce Taskforce could be the catalyst for designing an approach to capture this infor-mation in an ongoing process.

B. Conduct intervention/effectiveness research.

Social work researchers in partnership with nursing home social work practitioners and research colleagues of other discipline should begin rigorous studies of the im-pact of social work care processes to demonstrate the con-tribution of social work interventions to valued resident and home outcomes.

• Convene a small working group of social work research-ers and practitioners to develop a detailed research agenda for professional practice in nursing homes.

• Pursue opportunities for collaboration with large-scale multidisciplinary research efforts in NHs where a so-cial work practice component could be conceptualized and tested as part of the overall effort (e.g. depression care improvement; end-of-life care improvement).

• Undertake research using existing CMS measures and federal and state data bases (for example numbers of depressed residents as a mental health outcome) to study social work practice. To illustrate, the process of monitoring the continuity and impact of mental health treatment in transitional care for sub-acute patients has been identified as problematic and implicated in

persistent morbidity. This process could be the target of social work case management to test for increased effectiveness.

• Use reliable, state-of-the-art QOL measures (e.g., Kane, 2003) for intervention research on social work practice at both the resident (micro) and overall facility (macro) levels.

• Conduct comparison analyses of social work practice in “culturally transformed” environments versus “tra-ditional” homes.

• Conduct needs assessment research on the true extent of unmet psychosocial need in NHs and identify the most prevalent barriers.

C. Increase social work involvement in federal processes and initiatives and national reform efforts.

This is a multi-faceted effort, potentially involving all the components of professional social work. Recognition of so-cial work’s contribution to care rests in part on increasing the visibility of social work’s expertise and viewpoint in the wider deliberations and conversations that surround policy decisions, including those promoted by the nursing home industry. Social work practitioner and researcher expertise is needed for federal measurement initiatives and modi-fications to better capture data relevant to psychosocial concerns and interventions. Political advocacy for stronger standards for social work and psychosocial care in nursing homes is needed and must draw upon credible evidence for the value of professional personnel. Finally, social work involvement in shaping, testing, and ultimately advocating for transformations to care is as critical as efforts to influ-ence what now exists.

• Create a national virtual network of social work nurs-ing home experts to improve the visibility of existing NH practitioner networks and social work research-ers, strengthen their collaboration, and facilitate their identification and involvement in CMS initiatives, in-cluding modifications to care planning protocols, com-puterized assessment tools, and enhanced surveyor guidelines for assessing adequacy of psychosocial care and social services.

• Strengthen organizational social work involvement in nursing home practice improvement (e.g. NASW, As-sociation for Gerontology Education in Social Work) at CMS, AHRQ, the Department of Veterans Affairs, and the Health Resources and Services Administra-tion, by providing expertise to national advisory com-mittees and panels, and other national forums and meetings.


• Create a National Social Work Center on Long Term Care that would be a clear place of focus and consolida-tion for a range of professional information and effort. For example, a Center would promote links between Hartford Foundation initiatives, NASW’s Center for Workforce Studies, NASW sections, the Associa-tion of Veterans Affairs Social Workers , the Institute for Geriatric Social Work, American Society on Ag-ing, and the National Citizens Coalition for Nursing Home Reform. A Center would provide social work leadership for national strategies to promote culture transformation and stronger federal requirements for QOL that have the potential to improve nursing home care in fundamental ways.

Conclusion

According to the Centers for Medicare and Medicaid Ser-vices, There are currently close to 17,000 nursing homes in the United States. The challenges of strengthening so-cial work’s contribution to improving care arise on many fronts. Educational opportunities to prepare for nursing home practice could be made more attractive to students through the gerontological practice enrichment initiatives that are now underway, but require sustained attention and creativity similar to that exercised on behalf of child welfare. Realistically, many smaller and rural area homes will be unable to attract and employ a full-time trained so-cial worker. Field education and practice models for high quality social work consultation roles are needed. The uni-versity-field collaboration around nursing home care is a natural point of exchange and partnership, one that could potentially draw in additional partners such as long term care ombudsmen and consumer advocates to build a com-prehensive view of care delivery and improvement. Such partnerships could be the foundation for practice enhance-ment efforts in developing practice guidelines, evaluation tools, and conducting effectiveness research, if schools and long term care settings would undertake partnership initia-tives that go beyond the training mandate.

Partnership strategies are crucial to successful action in all arenas. Many needed initiatives require funding, wheth-er from foundations or government. Interdisciplinary col-laboration is essential for success. Other disciplines, such as nursing, share social work’s manpower and quality of life concerns and can be allies. Social work’s practitioners and educators must connect and contribute to the programs and initiatives of organizations representing the nursing home industry as well as those representing consumers. Federal agencies and federal social workers within these agencies

can be important partners in the profession’s efforts.

Social work expertise in nursing home practice is scat-tered and currently no national organizational structure in the profession offers a platform or dedicated resource to coalesce and maintain a working “interest group.” How-ever, there are state-level groups that could perhaps be the foundation of a “building from the bottom up” approach. The mechanism for achieving a national critical mass of interest and expertise, involving practitioners and academi-cians, must be found.

The path and case for cultural transformation of “nurs-ing homes” is rooted in the centrality and defining nature of resident and family perceptions of the quality of their psychosocial reality. This radical re-definition, focusing on resident-centered care, has the striking effect of plac-ing the social work perspective in the forefront, and carries with it the potential for social work roles and functions unfettered by current policies and regulations pertaining to social service delivery. But the necessary work remains of practice specification that promotes consistency, guideline development to assure that consistency is “best practice,” and investigation into the effects of consistent best-practice interventions on actual quality in the home. The profes-sion’s contribution to care improvement must be forward looking, and include the courage to undertake the neces-sary strengthening of its fundamental tasks in psychosocial service provision.

References

American Geriatrics Society and American Association for Ge-riatric Psychiatry. (2003). Consensus statement on improving the quality of mental health care in US nursing homes: Man-agement of depression and behavioral symptoms associated with dementia. Journal of the American Geriatrics Society, 51, 1287–1298.

Beaulieu, E. M. (2002). A guide for nursing home social workers. New York: Springer.

Burns, B. J., Wagner, H. R., Taube, J. E., Magaziner, J., Permutt, T. & Landerman, L. R. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331–337.

Castle, N. G., & Shea, D. G. (1997). Mental health services and the mortality of nursing home residents. Journal of Aging and Health, 9, 498–513.

Centers for Medicare and Medicaid Services. (1989). Require-ments for long term care facilities, 42 Code of Federal Regula-tions, Subpart B. Washington, DC: Author.

Department of Health and Human Services, Office of Inspector General. (2003). Psychosocial services in skilled nursing facilities.


Retrieved April 1, 2005, from http://oig.hhs.gov/oei/re-ports/oei-02-01-00610.pdf

Department of Veterans Affairs, Office of Social Work Services. (2001). Social worker functions in long-term care settings. Available from the Department of Veterans Affairs, Office of Social Work Services, Washington, DC.

Fagan, R.M., Williams, C.C. & Burger, S.G. (1997). Meeting of pioneers in nursing home culture change. Rochester, NY: Lifespan of Greater Rochester.

Greene, R. R. (2004, December). Roles and functions of nursing home social workers in the provision of psychosocial care. Paper pre-sented at the conference Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement, Washington, DC.

Kane, R. L. & Kane, R. A. (2000). Assessment in long-term care. Annual Review of Public Health, 3, 659–686.

Kane, R. A., Kling, K. C., Bershadsky, B., Kane, R. L., Giles, K. et al. (2003). Quality of life measures for nursing home residents. Journal of Gerontology: Medical Sciences, 58A(3), 240–248.

Kane, R. A. (2003). Definition, measurement, and correlates of quality of life in nursing homes: Toward a reasonable practice, research and policy agenda. The Gerontologist, 43 (Special Issue II), 28–36.

Kane, R. L., Bershadsky, B., Kane, R. A., Degenholtz, H. H., Liu, J. et al. (2004). Using resident reports of quality of life to distinguish among nursing homes. The Gerontologist, 44, 624–632.

Kruzich, J. M. & Powell, W. E. (1995). Decision-making influ-ence: An empirical study of social workers in nursing homes. Health & Social Work, 20, 215–222.

Meeks, S., Jones, M. W., Tikhtman, V. & LaTourette, T. (2000). Mental health service in Kentucky nursing homes: A survey of administrators. Journal of Clinical Geropsychology, 6, 223–232.

National Association of Social Workers. (1993). NASW clinical indicators for social work and psychosocial services in nursing homes. Washington, DC: Author.

National Association of Social Workers. (2003). Standards for so-cial work services in long-term care. Washington, DC: Author.

Nursing Home Reform Act of 1987, 42 U.S.C. § 1396 et seq.

Pioneer Network. (n.d.). What is culture change? Retrieved May 18, 2005, from http://www.pioneernetwork.net.

Quam, J. K., & Whitford, G. S. (1992). Educational needs of nursing home social workers at the baccalaureate level. Geriat-ric Social Work Education, 18(3/4), 143–156.

Rosen, A. L., Zlotnik, J. L. & Singer, T. (2002). Basic geronto-logical competence for all social workers: The need to “geron-tologize” social work education. Journal of Gerontological Social Work, 39, 25–36.

Shea, D. G., Russo, P. A. & Smyer, M. A. (2000). Use of mental health services by persons with a mental illness in nursing facilities: Initial impacts of OBRA 87. Journal of Aging and Health, 12, 560–578.

Simons, K. (2005). Factors affecting nursing home social workers’ quit-ting intentions. Unpublished doctoral dissertation, University of Maryland, Baltimore.

Snowden, M., Piacitelli, J., Koepsell, T. (1998). Compliance with PASARR: Recommendations for Medicaid recipients in nursing homes. Journal of the American Geriatrics Society, 46, 1132–1136.

Vinton, L., Mazza, N., & Kim, Y. (1998). Intervening in family-staff conflicts in nursing homes. Clinical Gerontologist, 19(3), 45–67.

Vourlekis, B. S., Gelfand, D. E. & Greene, R. R. (1992). Psycho-social needs and care in nursing homes: Comparison of views of social workers and home administrators. The Gerontologist, 32, 113–119.

Vourlekis, B. S., Bakke-Friedland, K., & Zlotnik, J. L. (1995). Clinical indicators to assess the quality of Social Work servic-es in nursing homes. Social Work in Health Care, 22, 81–93.

Wiener, J. (2003). An assessment of strategies for improving qual-ity of care in nursing homes. The Gerontologist, Special Issue II, 43, 19–27.


APPENDIX A


Conference Agenda

December 2–3, 2004

Vista Ballroom B, Wyndham Hotel

1400 M Street NW, Washington, DC

Thursday, December 2, 2004

8:30–9:00

Registration and Continental Breakfast

9:00–9:30

Welcome, Introductions and Overview of the Meeting Pur-poses and Planned Outcomes

Joan Levy Zlotnik, Institute for the Advancement of Social Work Research

Charlotte Mullican, Agency for Healthcare Research and Quality

Jesse Harris, University of Maryland, School of Social Work

Scott Miyake Geron, Institute for Geriatric Social Work, Boston University

9:30–10:45

Roles and Functions of Nursing Home Social Workers in the Provision of Psychosocial Care

Presenter: Roberta Greene, University of Texas, Austin, School of Social Work

Discussant: Patricia Gleason-Wynn, Baylor University, School of Social Work

Break

11:00–11:20

DHHS OIG Report on Psychosocial Care in Nursing Homes

Ellen Vinkey, Office of Inspector General, U.S. Depart-ment of Health and Human Services

11:20–1:00

Regulatory Approaches to Measuring Psychosocial Service Quality

Bob Connolly, Anita Panicker, and Jeane Nitsch, Centers for Medicare & Medicaid Services

Discussant: Betsy Vourlekis, University of Maryland

1:00–2:00 PM

Working Lunch: Roundtable Exchanges and Discussion

2:15–3:30

Meeting the Mental Health Needs of Nursing Home Resi-dents Using an Outcomes Approach

Ira Katz, University of Pennsylvania, School of Medicine

Discussant: Margaret Adamek, Indiana University, School of Social Work

Break

3:45–5:00

Small workgroups: Identifying barriers to measuring and monitoring psychosocial and social work service quality

Friday, December 3, 2004

8:30–9:45

Working Breakfast (provided) and Presentation

Measuring the Quality of Life in Nursing Homes and Its Relationship to Psychosocial Services

Presenter: Rosalie Kane, University of Minnesota, School of Public Health


Discussant: Rhonda Montgomery, University of Wiscon-sin, Milwaukee, Helen Bader School of Social Welfare

Break

10:00–11:00

The Philosophy and Strategic Implementation of Culture Transformation: Implications for Psychosocial Care Mea-surement in Nursing Homes

Presenter: Christa Hojlo, Veterans Health Administration

11:15–12:15

Small workgroups: Recommendations for measuring and monitoring psychosocial and social work service quality

12:30–1:30

Working lunch

1:30–2:15

Small workgroups: Implementation and dissemination ac-tion steps

Break

2:30–3:45

Workgroups report: Developing an action plan for mea-suring, monitoring, and research on psychosocial service quality

3:45–4:00

Concluding statements/response

Joan Levy Zlotnik, IASWR


APPENDIX B


Summaries of Conference Presentations

Roles and Functions of Nursing Home Social Workers in the Provision of Psychosocial Care (p. 13)

Presenter: Roberta Greene, University of Texas, Austin

DHHS OIG Report on Psychosocial Care In Nursing Homes (p. 15)

Presenter: Ellen Vinkey, Office of Inspector General, U.S. Department of Health and Human Services

Regulatory Approaches to Measuring Psychosocial Service Quality (p. 17)

Presenters: Bob Connolly, Anita Panicker, and Jeane Nitsch, Centers for Medicare & Medicaid Services

Meeting the Mental Health Needs of Nursing Home Residents Using an Outcomes Approach (p. 21)

Presenter: Ira Katz, University of Pennsylvania, School of Medicine

Measuring the Quality of Life in Nursing Homes and Its Relationship to Psychosocial Services (p. 23)

Presenter: Rosalie Kane, University of Minnesota, School of Public Health

The Philosophy and Strategic Implementation of Culture Transformation: Implications for Psychosocial Care Measurement in Nursing Homes (p. 25)

Presenter: Christa Hojlo, Veterans Health Administration


Roles and Functions of Nursing Home Social Workers in the Provision of

Psychosocial Care

Roberta R. Greene, PhD

University of Texas, Austin, School of Social Work

Overview

This presentation examined the congruence of psycho-social functions among five sources and related the result-ing common functions to the Council on Social Work Education (CSWE), Strengthening Aging and Gerontolo-gy Education for Social Work (SAGE-SW) project’s Geron-tological Social Work Competencies (CSWE SAGE-SW, 2001). Dr. Greene suggested that the resulting matrix be used (1) to establish a common framework for practice and education and (2) to operationalize measurement of key social work activities in the nursing home (NH) in relation to key patient and total home outcomes.

Sources for NH Social Work Functions

• Educational needs and practice realities of NASW members working in nursing homes (Greene, Vourle-kis, Gelfand, & Lewis, 1992)

• Psychosocial needs and care in nursing homes (Vourle-kis, Gelfand, & Greene, 1992)

• Social worker functions in long-term care settings (Cod-ified VA social worker practice standards, VA, 2001)

• Standards for social work services in long-term care fa-cilities (NASW standards, NASW, 2003)

• University of Texas Nursing Home Study (Greene et al., 2004)

• CSWE SAGE-SW Gerontological Social Work Com-petencies: 65 gerontological social work competencies, developed through a literature search and input from national experts, were fielded in 2000 through a large, national survey of practitioners and academics with ag-ing and non-aging interests. Survey respondents were asked to rank the level of specialization (1=all social workers, 2=advanced practitioners, and 3=aging spe-cialists) needed across three domains: (1) knowledge about older people and their families; (2) professional skill; and (3) professional practice. Each competency was rank ordered according to its mean level of special-ization. Results of this work can be found at: http://www.cswe.org/sage-sw/resrep/competenciesrep.htm

Common Functions and Related Educational Competencies

1. Conduct assessments through information gathering.

• Knowledge of normal physical, psychological, and social change in later life

• Knowledge of models of biology and social aging

• Skill to gather information regarding social history including social supports, culture, and social in-volvement

• Skill to gather information on mental status, his-tory of any past or current psychopathology, life satisfaction, coping abilities, affect, and spiritual-ity

• Skill to gather information on physical status in-cluding disabilities, chronic and acute illness, medications, mobility and activities of daily living

• Skill to conduct a comprehensive biopsychosocial assessment

• Skill to assess short-term memory, coping changes, socialization patterns, behavior, and appropriate mood and affect

2. Provide psychosocial interventions that enhance cop-ing skills.

• Skill to assist individuals and families in recog-nizing and dealing with issues of grief, loss, and mourning

• Skill to enhance the coping capacities of older adults

• Skill to assess psychosocial factors that have an ef-fect on the physical health of older adults

• Skill to use empathetic interventions such as remi-niscence or life review, support groups, and be-reavement counseling (total congruence)

• Engage and mediate with angry, hostile, and resis-tant older adults and family members

3. Assist with long-term care transitions through case management.

• Skill to use social work case management strate-gies such as brokering, advocacy monitoring, and discharge planning to link elders and families to resources and services

• Skill to assist older persons with transitions to and from institutional settings

• Conduct long-term care planning with older per-


sons and their families to address financial, legal, housing, medical, and social needs

4. Participate in care planning.

• Skill to develop service plans that incorporate ap-propriate living arrangements and psychosocial supports for older persons

• Skill to set realistic and measurable objectives based on functional status, life goals, symptom management, and financial and social supports of older adults and their families

• Skill to reevaluate service or care plans for older adults on a continuing basis, incorporating physi-cal, social, and cognitive changes and adjusting plans as needed

• Skill to develop service plans that include intergen-erational approaches to the needs and strengths of older persons, their families, or significant other

5. Collaborate with the nursing home team.

• Skill to collaborate with other health, mental health, and allied health professionals in deliver-ing services to older adults

6. Attend to individualized decision making.

• Skill to accept, respect, and recognize the right and need of older adults to make their own choices and decisions about their lives within the context of the law and safety concerns

• Skill to identify ethical and professional bound-ary issues that commonly arise in work with older adults and family members

References

Council on Social Work Education/Strengthening Aging and Gerontology Education in Social Work. (2001). CSWE SAGE-SW national aging competencies survey report. Retrieved May 17, 2005, from http://www.cswe.org/sage-sw/resrep/competenciesrep.htm

Department of Veterans Affairs, Office of Social Work Service (2001). Social worker functions in long-term care settings. Available from the Department of Veterans Affairs, Office of Social Work Services, Washington, DC.

Greene, R. R. , Graham, S., Haulotte, S., Nixon-Garica, C., Glea-son-Wynn, P. (2004). A state nursing home crisis: A consumer study in quality care. Unpublished manuscript, University of Texas at Austin.

Greene, R.R, Vourlekis, B.S., Gelfand, D.E., & Lewis, J.S., 1992 Current realities: Practice and education needs of social work-ers in nursing homes. Geriatric Social Work Education, 18(3/4), 39–54.

National Association of Social Workers. (2003). Standards for so-cial work services in long-term care. Washington, DC: Author.


Psychosocial Services in Skilled Nursing Facilities

Ellen Vinkey

Office of Inspector General, U.S. Department of Health and Human Services

Overview

This presentation reviewed the Office of Inspector General’s findings from their recent inspection related to psychosocial services in skilled nursing facilities (SNFs). Suggestions were made for research to further identify bar-riers to psychosocial care.

Review of Regulations (OBRA, 1987—Nursing Home Reform Act of 1987)

1. All SNFs must provide “medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident”

2. Facilities with over 120 beds are further required to em-ploy a minimum of one full-time social worker with

• “At least a bachelor’s degree in social work or an-other human service field”

• “1 year of supervised social work experience in a health care setting working directly with individuals”

OIG Study

Data Sources

1. Random sample (N=299) recently admitted Medicare beneficiaries

• Social work credential review

• Medical record review of assessment and provision of psychosocial services

2. Stratified random sample (N=84) Medicare certified SNFs

• Telephone interviews with social work directors and nursing home administrators

3. Small purposive sample (N=32) state surveyors from eight states

• Monitoring of psychosocial services

4. Review of Online Survey and Certification Reporting System (OSCAR) data

• Psychosocial deficiency data

5. National Ombudsman Reporting System (NORS) data

• Complaints about psychosocial services

Major Findings

• Almost all the residents whose charts were reviewed had a psychosocial need.

> 39% of those with needs had inadequate care plans to address those needs

> 46% of those with psychosocial care plans did not receive all planned services

> 5% received none of their plans psychosocial services

• 15% of facilities were cited for psychosocial deficiencies.

> F-246 and F-250 the most cited (lack of provision of medically-related social services)

• 1% of NORS complaints related to psychosocial services

• 98% of larger facilities (those with over120 beds) met the “120-bed rule.”

• 45% of social workers reported barriers to the provi-sion of psychosocial services.

> not having enough time

> burdensome paperwork

> insufficient staff (social workers and others)

> role ambiguity—performing roles that they were not trained to do

OIG (2003) Recommendation

“We recommend that the Centers for Medicare and Med-icaid Services (CMS) strengthen the oversight processes as-sociated with the psychosocial service portion of the resident assessment and the resulting care plans to ensure that SNF residents receive necessary and appropriate care (p. iv). ”

Possible Areas for Future Research

• Compare graduate by undergraduate social work prep-aration using the random sample (N=84) social work-ers interviewed.


• Develop additional means of measuring unmet psy-chosocial needs.

• Investigate the causes of the problem: What needs to be changed?

• Follow-up on the barriers to psychosocial service deliv-ery as reported by the 45% of social workers.

Reference

Department of Health and Human Services, Office of Inspector General. (2003). Psychosocial services in skilled nursing facilities. Retrieved May 9, 2005, from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf


Regulatory Approaches to Measuring Psychosocial Service Quality

Bob Connolly, MSW, LCSW-C

Jeane Nitsch, MS, MSW, LCSW-C

Anita Panicker RN, MSW, LCSW

Centers for Medicare & Medicaid Services (CMS)

Overview

This presentation reviewed federal regulations relative to nursing home (NH) psychosocial services and described the barriers to social work participation in quality improvement efforts. It further discussed Centers for Medicare and Med-icaid Services (CMS) quality improvement initiatives and suggested the need for social workers to play a larger role in the development of NH regulation and quality measures.

Barriers to Improving NH Psychosocial Competencies and Skills

• Focus is more on the medical model rather than psy-chosocial and psychiatric concerns

• A need to evolve psychosocial measures and assessment tools

• Lack of professional training and research skills among NH social work staff

• Staff turnover

• There are few social work, nursing, etc. students inter-ested in NH careers

• There is no body of evidence that level of education makes a difference in the quality of psychosocial ser-vices (e.g., having a BA in a human service field versus a bachelor’s degree in social work [BSW] or a master’s in social work [MSW])

Barriers to Social Work Involvement in Strengthening Psychosocial Care

• No national story about the social work role and con-tributions to the quality of care

• Social work role definition in NHs can be unclear

• Social workers need to better connect clinical process to resident outcomes (i.e., lack of evidence of clinical accountability)

• Limited visibility of social worker as a stakeholder

• Schools of social work can do more to train students for gerontological practice, which speaks to the need for curriculum development and development of NH field placements

Review of Long-Term Care Regulations 42 CFR 483 Related to Social Services Requirements at:

Sec. 483.15 Quality of life.

1. The facility must provide medically-related social ser-vices to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

2. A facility with more than 120 beds must employ a qual-ified social worker on a full-time basis.

3. Qualifications of social worker. A qualified social worker is an individual with

(i) A bachelor’s degree in social work or a bachelor’s degree in a human services field including but not limited to sociology, special education, rehabilita-tion counseling, and psychology; and

(ii) One year of supervised social work experience in a health care setting working directly with individuals.

Guidelines (State Operations Manual)

Intent §483.15(g)

• To assure that sufficient and appropriate social services are provided to meet the resident’s needs.

Interpretive Guidelines §483.15(g)

• Regardless of size, all facilities are required to provide for the medically-related social service needs of each resident. This requirement specifies that facilities ag-gressively identify the need for medically-related social services, and pursue the provision of these services. It is not required that a qualified social worker necessar-ily provide all of these services. Rather, it is the respon-sibility of the facility to identify the medically-related social service needs of the resident and assure that the needs are met by the appropriate disciplines.

Examples of Social Work Involvement in NH Regulatory Change

• Advocacy through Congress regarding CMS changes in conditions of participation or staffing requirement


• Initiation of the DHHS Office of Inspector General (2003) study: Psychosocial Services in Skilled Nursing Facilities

• A DHHS national meeting on long-term care social work (September, 2002)

• Report to Congress: The future supply of long-term care workers in relation to the aging baby boom gen-eration (DHHS Assistant Secretary for Planning and Evaluation, 2003)

• AHRQ-funded, 2004 interdisciplinary meeting: Evalu-ating social work services in nursing homes: Toward quality psychosocial care and its measurement.

• John A. Hartford Foundation funding (Hartford Geri-atric Social Work Initiative)

CMS NH Social Work Best Practice Study

Hypothesis. Social workers in “best-practice” NH are includ-ed in more interdisciplinary care, have better defined roles and make quality contributions to resident psychosocial care

Best-practice nursing home selection based on

• 2001 CMS Environmental Scan

• Recommendations from CMS NH experts

• Amount of survey and certification deficiencies

• Publicly reported quality measures

Survey sample

• National telephone interviews were conducted using a standardized survey tool

• Participants of the survey consisted of 25 best-practice nursing home social workers or social service providers

> 1 social work consultant

> 1 nursing home administrator

> Average facility bed size=97.48 beds

> Mostly middle-to-small nursing homes

Education credentials

• All best-practice nursing homes had a social service provider. Most of these providers (85%) were qualified social workers.

> 9 BSW

> 1 BA

> 12 MSW

> 3 designees (associate’s degree or less)

Most common roles (social worker’s self-report)

* Supportive care (72%)

> Family support

> Residents’ rights

> Quality of life issues

• Documentation (69%)

> Completion of MDS, care plans, etc.

• Direct social services (56%)

> Individual

> Family

> Groups

Roles ranked most important to medically related social services (n=26)

• Care planning (73%)

• Family Support (73%)

• Psychosocial Assessment (69%)

• Training Staff (62%)

• Counseling (39%)

• Discharge planning (39%)

Interdisciplinary roles

• Care planning with nursing, activities coordinator, MDS coordinator, and physician

• Discharge planning with nursing, activities coordina-tor, MDS coordinator, dietary, therapy, and physician

• 90% of best-practice social workers led or co-led most family and resident counsel groups with the activi-ties coordinator (46%), administrator (36%), nursing (18%)

Minimum Data Set (MDS) documentation

• Most best-practice social workers (85%) took part in the initial MDS

Most frequently answered social work MDS questions

• Section F. Psychosocial well-being

> Question 1. Sense of initiative and involvement (96%)

• Section E. Mood and behavior

> Question 1. Indicators of depression, anxiety, sad mood (67%)

> Question 3. Mood persistence (89%)

> Question 4. Behavioral symptoms (89%)


• Section Q. Discharge potential

> Question 1. Discharge potential (74%)

• Section B. Cognitive patterns

> Question 5. Indicators of delirium/period of dis-ordered thinking (52%)

Qualitative findings

• Best-practice social workers appear satisfied and well utilized

> They are very satisfied with their roles and functions

> Feel needed and valued as members of interdisci-plinary team

> Feel respected for the skills and services they pro-vide

Evidence

• Consistent role definition for social work across 26 NHs

• Involvement in all aspects of care planning

• Social workers reported being satisfied and well utilized

Study Limitations

• Small sample

• Study focused on medium-sized facilities only

• There were no specific “data” that could point to the social worker’s contribution to improved quality of care or facility performance on pain, pressure ulcer, or restraints quality measures.

Proposed MDS 3.0 Revisions Relevant to Social Work (www.cms.hhs.gov/quality/mds30/DraftMDS30.pdf)

Delirium. Section B

• New yes/no standardized delirium questions based on the Confusion Assessment Method (CAM)

> CAM is a valid, reliable, and quick way for non-psychiatric clinicians to detect delirium (Inouye et.al., 1990) and is also recommended by the 2002 Mood/Behavioral Expert Panel

Quality of Life (QOL). Section F

• CMS contract 1998–2003 with University of MN

• Developed 11 domains of QOL

• See also: www.cms.hhs.gov/quality/mds30

Select Current CMS Quality Measures With Psychosocial/Psychiatric Components

• Depressed/anxious mood worsening

> Percent of residents who have become more de-pressed since the last time they were assessed

• Moderate/severe pain

> Percent of residents with moderate or severe pain during a 7-day assessment period

• Delirium

> Percent of recently admitted residents from a hos-pital who have symptoms of delirium, defined as: sudden problems with attention, problems with thinking and communicating, loss of a sense of time and place, changes in sensation and percep-tion, changes in level of alertness, changes in sleep patterns, loss of short-term memory, restlessness and changes in personality.

> See also: www.cms.hhs.gov/quality/nhqi

Conclusions: Social Work Opportunities in NH Regulatory Change

• 29 Current CMS MSWs are using the following ap-proach to nursing home improvements that could be a model for the social work profession.

> Promote NH social work using macro skills on a policy level and not just on a direct-practice level.

> Focus on improving the quality of life psychoso-cial and psychiatric nursing home residents need, as nursing home social work roles are not well de-fined and have produced limited data.

> Seek solutions to upgrade the practice and training of social workers in nursing homes including non-MSW and non-BSW nursing home social workers. (It will take years to supply BSW and MSW man-power to over 17,000 nursing homes and more work is needed on the social work role definition and qualifications.)

> Network and collaborate with nurses, physicians, therapists, activities professionals, and others to push for improved care, as nursing home quality of care and quality of life concerns are common to all professions. (Social work skills are most needed, appreciated, and dynamic in an interdisciplinary model.)


> Be a voice/advocate for nursing home resident needs at national, state and local forums because policy and decision making are often based on provider, legislative, or payer needs.

• Work with other professions to address NH workforce issues.

> Nursing schools are having the same problems at-tracting students, faculty and long-term-care (LTC) researchers.

• Accountability and interdisciplinary care

> There is a need for social research and technical expert panels to better define the social work role, interdisciplinary tasks and the processes, outcomes and contributions that this profession makes in nursing facilities.

• Conduct LTC quantitative and qualitative research through academic centers.

> Schools of social work are not focused enough on LTC in terms of curriculum, faculty interest, field placements, and research.

> Identify and provide CMS with roster of LTC so-cial work experts

> Use CMS quality measures that are updated quarter-ly for close to 17,000 Medicare/Medicaid-certified nursing homes: <www.medicare.gov/NHCompare/Home.asp> and <www.cms.hhs.gov/quality/nhqi>

• Work with other disciplines/agencies (e.g., National Institute of Mental Health and Department of Veter-ans Affairs) to study depression.

• Become involved in LTC monthly open-door forums: <http://www.cms.hhs.gov/opendoor/snf-ltc.asp>.

• Present at multidisciplinary NH stakeholder meetings and partner with NH organizations (i.e., American Association of Homes & Services for the Aging for non-profit NHs, American Health Care Association for-profit NHs, American Hospital Association for hospital-based NHs).

• Comment on drafts of MDS, Interpretive Guidelines, Federal Register Notices, Consumer Assessment of Health Plans Survey drafts, etc.

• Promote regulations and State Operations Man-ual guidelines to NH social work practitioners: <http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp> and <http://www.cms.hhs.gov/manu-als/107_som/som107_appendixtoc.asp>.

References

Department of Health and Human Services, Assistant Secretary for Planning and Evaluation. (2003, May). Report to Congress: The future supply of long-term care workers in relation to the ag-ing baby boom generation. Retrieved May 9, 2005, from http://aspe.hhs.gov/daltcp/reports/ltcwork.htm

Department of Health and Human Services, Office of Inspector General. (2003). Psychosocial services in skilled nursing facilities. Retrieved May 9, 2005, from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The con-fusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941–948.


Meeting the Mental Health Needs of Nursing Home Residents Using an

Outcomes Approach

Ira R. Katz, MD, PhD

University of Pennsylvania, School of Medicine

Overview

This presentation defined conceptual models of the mental health and nursing home (NH) care systems in rela-tion to psychosocial services, described the impact of these care systems on the treatment of residents with depression and dementia, and challenged current treatment protocol relative to these two mental health conditions.

Application of the Two-System Model (Table 1)

• The intrinsic system is critical for prevention, as a sole treatment for milder conditions, and as a vehicle for implementing specific care plans. Within the facility, ser-vices must almost always be mediated through the intrinsic system.

• The extrinsic system is more likely to be necessary with more severe disorders.

• All residents are dependent and all are vulnerable to

the NH environment. The more impaired a resident may be, the more likely s/he is affected.

Interactions Between Intrinsic and Extrinsic Systems

• For psychotherapy/behavioral treatment, staff and pro-grams are part of the solution or part of the problem

• For pharmacotherapy, facility staff is critical for:

> Screening and referral

> Evaluation of target symptoms and assessment of outcomes

> Evaluations of side effects

Role of Social Work

• Is critical for the inner mental health system

• Should be an important part of the outer system (e.g., by providing Part B services)

• Is the best candidate for bridging between the two sys-tems and supporting their interactions

Table 1. Two-System Model of Nursing Home Systems and Mental Health Systems for Nursing Home Residents

Two Nursing Home Systems

Long Term Care Subacute Care

Accounts for most beds Accounts for most people

Emphasizing person-environment fit Transitional care issues

Addressing mental health conditions as Addressing mental health conditions as barriers

key determinants of quality of life to rehabilitation, recovery, and readjustment

Two Mental Health Systems for NH Residents

Intrinsic/Inner Extrinsic/Outer

Universal services Specialty services

All aspects of NH life and care should be Focused on diagnosed mental disorders

informed by knowledge of the mental disorders of

late life and of older people’s vulnerabilities to them

Interface between quality of care and quality of life Interface between psychosocial care and general

medical care

Mental health services are provided by all staff Provided by mental health specialty professionals

Medicare “Part A” Medicare “Part B”


Depression

Definition of depression. A lack of positive affect

Prevention. Is there less depression in facilities with higher quality of care/quality of life?

Question. How can we deliver effective treatment for de-pression to real people in real nursing homes?

Conclusions

• The rapid rise in antidepressant use in NHs corre-sponds with a decrease in antipsychotics use.

• There is an overall lack of effective diagnosis and fol-low-up and an over-reliance on pharmaceutical inter-ventions for depression in NHs.

• The efficacy of antidepressants on minor depressions has yet to be established among this population of old-er adults. There is more evidence of efficacy for major depression.

• There is a need to distinguish between reactions to poor quality NH environments versus true depression.

Dementia

Major concern. Problematic behaviors that cause serious problems

Question. How should we combine/ prioritize psychosocial and biomedical care for dementia?

Two nursing home treatment cultures

• Behavioral/environmental

• Biomedical/pharmacological

Causes of agitation

• Unmet physical and psychosocial needs: Pain/discom-fort and boredom/loneliness

> The environment may be too demanding or stimu-lating

> The environment may not be demanding or stimu-lating enough

Conclusions

• There are no simple answers to managing behavioral symptoms with dementia.

• Simple models are inadequate.

• Our research needs new conceptual models and designs.

• Our care systems must be reinvented.


Measuring the Quality of Life in Nursing Homes and Its Relationship to

Psychosocial Services

Rosalie A. Kane, PhD

University of Minnesota, School of Public Health

Overview

This presentation defined the concept of quality of life (QOL) as it relates to nursing homes (NHs), described and presented results of a study sponsored by the Centers for Medicare & Medicaid Services (CMS) to develop NH QOL measures, and provided suggestions for measuring and im-proving NH QOL.

QOL is not just lack of bad outcomes.

• It allows for older person’s voice (individual and cul-tural differences)

• It is multidimensional and subjective

• It includes physical, psychological, social, economic, and spiritual aspects

When measuring QOL

• It is critical to ask the resident about their QOL di-rectly before asking proxies or gathering data through observation. Even people with substantial dementia can tell you about their QOL.

Domains of quality of life measures for residents in care settings (proposed hierarchy of needs)

1. Comfort and security

2. Enjoyment, relationships, meaningful activity and functional competence

3. Individuality, privacy, autonomy, and dignity

4. Spiritual well-being

CMS QOL Study: 1998–2003

• Developed measures and indicators of QOL in NHs

• Studied how physical environments affect QOL

• Paved the way for QOL improvement efforts

• Sampled more than 3,000 residents in 100 NHs across five states

• Conducted 45–90 minute interviews with residents

• Measures:

> 56 items

> 3–6 items per domain

> Mostly 4-point Likert scales with a dichotomous (yes/no) fall-back

Brief findings

• The researchers were able to reliably measure QOL do-mains for an average of 60% of NH residents.

• Minimum Data Set (MDS) cognition questions were a poor predictor of the ability to interview.

• Many hypothesized indicators did not work because of the measuring strategy (across multiple facilities). It may be more feasible to measure indicators (program/facility aspects) and resident outcomes at the facility level.

• The reliability of the scales was good.

• Facility-level QOL showed patterns (generally good or bad across all domains).

• Family and staff proxies significantly correlated with resident self-report, though these correlations were weak.

• Responses to staff interviews were highly correlated to research interviewer’s responses and there were no significant differences between nurse and social work interviews.

• Having a single room related to multiple QOL domains.

• Personality has some effects on QOL, after controlling for functional status and cognition.

Internal and External Influences on QOL

• Health status including functional and sensory losses

• Social circumstances

• Personality (extroversion/introversion, neuroticism, creativity, etc.)

• Care provision/neglectful care

> Uncontrolled pain, hunger, sleep problems

> Untreated depression

> Excess disability due to lack of dentures, hearing aides, eyeglasses, foot care

• Care environment

> Involuntary moves (should be the last resort)

> Continuity of care

> Meaningful activity

> Maximization of independence


> Fostering relationships

• Public and professional attitudes

> Ageism

> Low expectations and pessimism

Select Questions to Identify Resident Strengths

• What makes a day a good day for you?

• What are the things you do each day or each week because you really prefer or choose, not because you must? What makes you get so involved that time seems to move quickly?

• What do you do well? What kinds of things did you previously do well? What has always given you confi-dence or made you proud?

Implications of Culture Change for Social Work Practice

Much of what social work stresses already fits with cul-ture-change perspectives and presents an opportunity for social work leadership.

• The person–environment perspective

• Focus on environmental interventions

• Knowledge of group process (which is important in Greenhouse environments that have 8–10-person houses instead of large units)

• Focus on family systems

• End of life and discharge planning

• Continuous quality improvement efforts

Implications of Culture Change for Psychosocial Measurement

• Measures for psychosocial outcomes are available. It’s just a matter of using them.

> There is an over-concern regarding resident burden.

• Measures for independent variables (i.e., psychosocial interventions and level of dose) are not as easy to come by and will need to be developed.

• It is important not to confuse indicators (facility pro-cess) with outcomes (resident well-being).


The Philosophy and Strategic Implementation of Culture Transformation:

Implications for Psychosocial Care Measurement in Nursing Homes

Christa M. Hojlo, DNSc, NHA

Veterans Health Administration

Overview

This presentation introduced the concept of nurs-ing home (NH) culture change and described how it has been applied in the Department of Veteran’s Affairs (VA) nursing home care units (NHCUs). It also related culture change to psychosocial care processes and cited opportuni-ties that have emerged in VA NHCUs as a result of cultural transformation.

The culture of health care in the United States

• Shaped by: funding/payment systems, specialization, in-stitutionalization, medicalization (over-medicalization)

• Strengths of system: interdisciplinary, attention to quality

Characteristics of the traditional VA nursing home care unit (NHCU)

• Medically driven by diagnosis

• Language is indicative of medical model—“patient”

• The environment is hospital based

• Length of stay tends not to be well defined

• Care regimens vary

• Prescribed expectation/norms of behavior for resi-dents (must get dressed, etc.)

• Strong commitment to serving veterans

Culture change defined

Culture change is not merely changing policies, proce-dures, and functions. It is the redefinition of care systems and our ways of understanding and interacting within them: “not only of what we do, but how we do it; how we think about how and what we do.”

Characteristics of new culture

• The driver of care is improvement in quality of life (QOL) and in maintaining residents’ highest practi-cable functional level.

• Care is resident focused. Discipline-specific boundar-ies are blurred to meet residents’ needs. (“It doesn’t matter who does it. All of us need to do it.”)

• Care is based on assessed needs and resources allocated to meet those needs in accord with resident wishes.

• The interdisciplinary team clearly understands its role in relationship to facilitating achievement of resident goals, determined on or prior to admission. Every member of the interdisciplinary team is responsible for achievement of these goals.

• The environment is more home-like and speaks to well-ness.

• Greater attention is paid to costs and service quality via resident satisfaction.

• At the heart of the transformation is changing the driv-er of care from the medical model to a model driven by nurturance, comfort, and love.

The symbolism of language change

• From “patient” to “resident”

• From “illness” to “highest practicable functional level”

Admission considerations

Three critical questions that help to identify the reason for admission, long- and short-term goals, and to start im-mediate discharge plans:

1. Why is the resident here/coming here?

• S/he lacks social or other structures/supports to facilitate achieving goals for improved function, in order to return to the community, or to receive comfort and care in dying. It is the role of the facil-ity and the interdisciplinary team to provide the structure to achieve this goal.

2. For how long will the resident need placement?

• If you know that the resident should achieve his/her functional goal in 30 days, then set up the sup-ports in the NHCU to discharge the resident in 30 days.

• Short term goals are measures of progress toward goal attainment.


3. Where will s/he go from here?

• Home

• Community NH

• Death

• Long-term stay

Why is this important?

These are critical questions that design and shape the culture of care relative to service delivery.

• Out of nurturance, comfort, and love, services are pro-vided for the resident to improve function/health or to die with dignity.

• Resident preferences are at the center of care.

• The philosophy guiding this model is one where rehab principles intersect to provide the highest quality of care based on assessed resident needs:

> The challenge is to find that one tiny area of well-ness that can be enhanced, regardless of diagnosis, which also discourages the sick role.

> Provide safety while encouraging independence, responsibility, and participation.

> Provide an approach where there is meaningful use of time: No time to wander aimlessly; TV as a personal preference; Engagement in life so there is no time for problematic behaviors.

Summary and Conclusions

The development of culture change (e.g. Eden Alterna-tive, Pioneer Network, and Wellspring) has presented many opportunities for the VA NHCU:

• Opportunity to understand and manage quality and costs in a systematic way

• Opportunity to shape the reconstruction of the MDS 3.0 through partnering with CMS

• Social work participation in MDS development is important.

• Opportunity for applied research from a culture-change perspective (e.g., the meaningful use of time)

• Opportunity to shape nursing home delivery for the VA and beyond

• Opportunity to let creativity out of the bag through a focus on well-being



Presenter and Discussant Biographies

APPENDIX C

Margaret E. Adamek, MSW, PhD

Margaret Adamek is the director of the PhD program in social work at Indiana University in Indianapolis, IN. As a member of the first cohort of Hartford Geriatric So-cial Work Faculty Scholars, she conducted a study focusing on depression among long-term care residents. Her other research interests include suicide among older adults and mental health policy.

Robert Connolly, MS, LCSW-C

Bob Connolly has worked primarily with quality mea-surement and quality improvement in nursing homes, hospitals, and home health agencies since beginning his government service in 1988. Since 2002, Bob has been the co-task leader for the Minimum Data Set, Version 3.0 (MDS 3.0) design and development team. At CMS he has developed partnerships with the Department of Veterans Affairs and the Agency for Healthcare Research and Qual-ity to enhance the MDS development. Prior to coming to CMS, Bob was the assistant director at the Johns Hop-kins Oncology Center, director of social work geriatrics at Union Memorial Hospital in Baltimore, and clinical social work lead at Children’s Hospital in Oakland, California.

Patricia Gleason-Wynn, PhD, LCSW

Pat Gleason-Wynn is currently a lecturer in the School of Social Work at Baylor University, Waco, Texas. Her pri-mary area of interest is gerontology with a particular focus on nursing home social work where she has practiced for over 25 years. She has provided, and continues to provide, consultation to numerous nursing homes and social work-ers in Texas. She is the current chair of the Committee on Aging-National Association of Social Workers Texas Chap-ter, and the aging delegate from Texas for the 2005 NASW Delegate Assembly.

Roberta Greene, PhD

Roberta Greene is professor and the Louis and Ann Wolens Centennial Chair in Gerontology and Social Wel-fare at the School of Social Work University of Texas at Austin. She previously was professor and dean at the Indi-ana University School of Social Work and has worked at the Council on Social Work Education and the National Association of Social Workers. Dr. Greene has authored numerous publications including Resiliency Theory: An Integrated Framework for Practice, Research, and Policy; Social Work With the Aged and Their Families; and Hu-man Behavior Theory and Social Work Practice.

Christa M. Hojlo, RN-C, DNSc, NHA

Christa Hojlo has been employed by the Department of Veterans Affairs since 1993. Currently she serves as chief of nursing home care for the Department of Veterans Af-fairs, responsible for national policy, quality, planning, and programming for the VA’s 133 nursing home programs. Currently she has initiated and provided leadership for the transformation of the culture of nursing home care in VA nursing homes. Prior to working at the VA she was a nursing home administrator in Maryland and taught at the Catholic University of America School of Nursing. She has taught the Nursing Home Administrator course in Mary-land and provided consultation and feedback on the use of the MDS for payment to the state of Maryland.

Rosalie A. Kane, PhD

Rosalie A. Kane is a professor of public health at the University of Minnesota, and a faculty member in the Cen-ter for Biomedical Ethics and the School of Social Work. Her research focuses on long-term care and she served on the Institute of Medicine’s Committee on Quality of Long-


Term Care (1998–2000). She led a 5-year national study on Measurement, Indicators, and Improvement of the Qual-ity of Life in Nursing Homes (funded by the Centers for Medicare & Medicaid Services) and a national study on the Home Care/Assisted Living Connection (funded by the Home Care Resource Initiative of the Robert Wood Johnson Foundation).

Ira R. Katz, MD, PhD

Dr. Ira Katz is a professor of psychiatry and director of geriatric psychiatry at the University of Pennsylvania Medical Center, as well as director of the Mental Illness Research Education and Clinical Center of the Philadel-phia VA Medical Center. He conducts research into the causes and treatment of depression and other psychiatric illnesses in the aged, especially among those institutional-ized in long-term care settings. He has also explored issues related to delirium and acute cognitive changes among the institutionalized aged. He is principal investigator of an NIMH-supported Center for Interventions and Ser-vices Research that is investigating depression in late life and psychiatric-medical comorbidity. He also serves on nu-merous professional and scientific societies including the Aging Committee of the Group for the Advancement of Psychiatry, and is past president of the American Associa-tion of Geriatric Psychiatry. He is an associate editor for the American Journal of Geriatric Psychiatry.

Rhonda J. V. Montgomery, PhD

Rhonda Montgomery holds the Helen Bader Endowed Chair in Applied Gerontology at the University of Wiscon-sin–Milwaukee where she is a professor in the School of Social Welfare and in the Department of Sociology. Prior to joining the faculty of UWM, she was the director of the Gerontology Center at the University of Kansas where she also served as the director of the Doctoral Program in Gerontology. Throughout her career, Dr. Montgomery has conducted numerous regional and national studies focused on public policy, the role of family, and the role of staff in providing long-term care. She has been the principal or co-principal investigator for more than 20 studies that have been supported by private foundations, the Alzheimer’s Association, the Administration on Aging, the National Institutes of Health, and the Health Resources Services Administration.

Jeane Nitsch, MS, MSW, LCSW-C

Jeane Nitsch works in the Division of Nursing Homes at the Centers for Medicare & Medicaid Services. Her pri-mary role is the development and implementation of na-tional policies for nursing homes in areas such as physical and chemical restraints use, abuse and neglect, and other quality-of-life issues pertaining to survey and certification. Prior to coming to CMS in 1998, she worked as the direc-tor of admissions and social work in a hospital-based sub-acute unit. Her experience has primarily been in nursing homes, as well as continuing care retirement communities, and assisted living facilities. Ms. Nitsch earned a master of social work degree specializing in aging from the Maryland School of Social Work, and she holds a master of science degree in Health Care Management from the University of Maryland University College.

Anita G. Panicker, RN, MS, LCSW, MSW

Anita G. Panicker works in the Office of Clinical Stan-dards and Quality at the Centers for Medicare & Medicaid Services (CMS). She is a Licensed Certified Social Worker and Registered Nurse. She brings her management and clinical experience from the hospitals, nursing homes, and residential treatment centers where she worked prior to joining CMS. She has master’s degrees in nursing and social work. At CMS she is the lead analyst for nursing homes. She has experience in writing regulation for nurs-ing homes, hospitals, hospice, and other providers. This includes researching, evaluating and analyzing the aspect of care, evaluating existing rules, and identifying needs for new regulations. She has been the project officer for the respiratory therapy study in nursing homes.

Ellen Vinkey, MS

Ellen Vinkey is a team leader in the U.S. Department of Health and Human Services Office of Inspector General. Her team is currently beginning an evaluation of wound-care services to Medicare beneficiaries. In addition to their recent work on Medicare psychosocial services, she has per-formed evaluations on a number of Medicare-related topics including the following: the medical review process utilized by Medicare carriers, the role of the physician in oversee-ing home health services, and access to post-acute services after hospital discharge. She has been with the OIG for 8 years. Prior to joining the OIG, she served as a manager in New York City government. She holds a master of science degree in urban policy analysis from the New School for Social Research.


Betsy Schaefer Vourlekis, PhD

Betsy Vourlekis is professor emerita of social work at the University of Maryland School of Social Work. She is currently co-principle investigator on intervention research projects testing case management, including screening and brief treatment for depression and anxiety, to improve ad-herence to diagnostic follow-up and adjuvant treatment in breast and cervical cancer screening and treatment, funded by the CDC and the NIH’s National Cancer In-stitute. She has served on the NIMH Task Force on Social Work Research (1988–1991) and chaired the follow-up Na-tional Implementation Committee (1991–1993). She was the project consultant and field researcher for NASW’s Clinical Indicator Guideline project that developed qual-ity improvement monitoring indicators for social work/psychosocial services in medical and psychiatric hospitals, nursing homes, hospice care, dialysis centers, and home health agencies.

Joan Levy Zlotnik, PhD, ACSW

Joan Levy Zlotnik, PhD, ACSW, has served as the execu-tive director of the Institute for the Advancement of Social Work Research (IASWR) since 2000, working to build so-cial work research resources and to translate research to practice, policy, and education. She is actively involved in the national policy arena, in regard to enhancing the well-being of disempowered populations, promotion of behav-ioral and social science research opportunities, responding to the demographics of aging, promoting evidence-based practices, and in addressing the child welfare workforce cri-sis. Previously she served as director of special projects and special assistant to the executive director at the Council on Social Work Education, and as staff director for the Com-mission on Families and Government Relations Associate at the National Association of Social Workers. She devel-oped and implemented legislative and regulatory strategies to advocate for prevention and early intervention services for vulnerable children, families, and older persons. Her areas of interest include aging, child welfare, workforce de-velopment, building community–university partnerships, and inter-professional and inter-organizational issues.


APPENDIX D

Margaret AdamekProfessorIndiana University School of Social Work

Elise BeaulieuConsultant, PhD studentSimmons College

Mercedes Bern-KlugHartford Geriatric Social Work Faculty ScholarUniversity of Iowa School of Social Work

Ashley BrooksCo-director, Gero-Ed CenterCouncil on Social Work Education

Mirean ColemanSenior Policy AssociateNational Association of Social Workers

Molly DavisAssociate ProfessorGeorge Mason University

Susan DavisCommunity Services MentorMeadowlark Hills

Thomas DuganAdministratorSt. John Vianney Center

Susan EnguidanosDirector, Research CenterPartners in Care Foundation

Colleen GalambosDirector and Associate ProfessorUniversity of Missouri–Columbia School of Social Work

Patricia Gleason-WynnLecturerBaylor University School of Social Work

Jesse HarrisDeanUniversity of Maryland School of Social Work

Sara HuntLong Term Care Consultant

Ira KatzDirector/Professor of Geriatric PsychiatryUniversity of Pennsylvania, Section on Geriatric Psychiatry

Philip McCallionProfessorUniversity at Albany, SUNY School of Social Work

Carmen MoranoAssociate ProfessorUniversity of Maryland

Ann MurfittManager Social ServicesHCR-Manorcare

Evvie MunleySenior Health Policy AnalystAmerican Association of Homes and Services for the Aging

Jeane NitschHealth Insurance SpecialistCenters for Medicare & Medicaid Services

Anita PanickerOffice of Clinical Standards and QualityCenters for Medicare & Medicaid Services

Warren Phelps Coordinator, Quality of LifeRoyal Management of LexingtonHealth Care Centers

Susan ReinhardProfessor and Co-directorRutgers, Center for State Health Policy

Judith SanglHealth Scientist AdministratorAgency for Healthcare Research and Quality

Barbara SoltSenior Program AssociateInstitute for the Advancement of Social Work Research


Conference Participants


Robyn StoneExecutive DirectorInstitute for the Future of Aging Services

Catherine TompkinsBSW Program DirectorGeorge Mason University

Dinh TranSocial Service ConsultantWisconsin Department of Health and Family Services, Bureau of Quality Assurance

Betsy VourlekisProfessorUniversity of Maryland, School of Social WorkUniversity of Maryland Baltimore County

Kelly WrightDirector of Social ServicesImmaculate Mary Home

Joan Levy ZlotnikExecutive DirectorInstitute for the Advancement of Social Work Research

Jean BadalamentiFamily Outreach CoordinatorNational Citizens Coalition for Nursing Home Reform

William BensonPresidentThe Benson Consulting Group

Linda BergofskySocial Science AnalystU.S. Department of Health and Human Services

Vicki BoyleProject ManagerMPRO (Michigan Health Care Quality Improvement Organization)

Brenda BustosAdministrative CoordinatorInstitute for the Advancement of Social Work Research

Robert ConnollyHealth Insurance Specialist, MDS 3.0 Development TeamCenters for Medicare & Medicaid Services

Kristin DayDeputy Director, Social Work ServiceDepartment of Veterans Affairs

Javier EvansNational Institute of Mental Health

Scott Miyake GeronDirector, Principal InvestigatorInstitute for Geriatric Social Work, Boston University

Roberta GreeneLouis and Ann Wolens Centennial Chair in Gerontology and Social WelfareUniversity of Texas at Austin

Bernice HarperMedical Care AdvisorU. S. Department of Health and Human Services

Christa HojloChief, Nursing Home CareDepartment of Veterans Affairs

Rosalie KaneProfessorUniversity of Minnesota

Stuart KauferTBI Waiver Regional Resource Development SpecialistCenter for Independence of the Disabled, New York

Ruth KneeSocial Work PioneersNational Association of Social Workers

Rhonda MontgomeryHelen Bader Endowed Professor of Applied GerontologyUniversity of Wisconsin–Milwaukee

Charlotte MullicanSenior Advisor for Mental Health ResearchAgency for Healthcare Research and Quality

Karen NeumanAssociate ProfessorVirginia Commonwealth University

Vivian OmagbemiProgram ManagerMontgomery County Health and Human Services

Lisa PetersonDirector of Social Services and AdmissionsMaplewood Park Place

Stephanie ReedAssociate Director, Government AffairsAmerican Association for Geriatric Psychiatry

Anita RosenSenior Projects AdvisorCouncil on Social Work Education

Kelsey SimonsDoctoral CandidateUniversity of Maryland, Baltimore, School of Social Work

Sidney StahlChief, Individual Behavioral Processes BranchNational Institute on Aging


Jeanette TakamuraDeanColumbia University School of Social Work

Rebecca ToniMSW InternInstitute for the Advancement of Social Work Research

Ellen VinkeyTeam Leader/AnalystOffice of Inspector GeneralOffice of Evaluation and Inspections

Elizabeth Law WatkinsProfessor Emerita, School of Public HealthUniversity of North Carolina at Chapel Hill

Sheryl ZimmermanProfessor of Social Work and Public HealthThe University of North Carolina at Chapel Hill


APPENDIX E


Internet Resources

Aging, Health, and Long-Term Care Organizations

American Association of Geriatric Psychiatry

http://www.aagponline.org/

The American Association of Geriatric Psychiatry (AAGP) is a national association representing and serv-ing its members and the field of geriatric psychiatry. It is dedicated to promoting the mental health and well-being of older people and improving the care of those with late-life mental disorders. Their website contains resources for families, caregivers, and professionals. Information geared toward health care professionals includes fact sheets and research overviews on the demographic characteristics of the elderly population. It also contains information about treating and diagnosing particular mental health challeng-es facing the elderly and information about accessing and financing mental health care. There is a job bank, funding opportunity listing, and AAGP fellowship information.

American Association of Homes and Services for the Aging

http://www2.aahsa.org/

The American Association of Homes and Services for the Aging (AAHSA) has a vision of advancing the vision of healthy, affordable, and ethical aging services for America. Their website provides an overview of AAHSA’s programs and initiatives such as Quality First. It also provides links to their various publications, provides information about upcoming conferences and events, and maintains a legisla-tive action center.

American Geriatrics Society

www.americangeriatrics.org/

The American Geriatrics Society (AGS) is a nationwide, not-for-profit association of geriatrics health care profes-sionals, research scientists, and other concerned individu-als dedicated to improving the health, independence, and quality of life of all older people. The website contains some member specific information as well as sections for the general public. There are also pages for the education arena listing educational products and resources, awards, funding opportunities, jobs, and a student section.

American Health Care Association

http://www.ahca.org/

The American Health Care Association (AHCA) is a nonprofit federation of affiliated state health organizations that represent the long-term care community to the nation at large. The website contains a portion specific to mem-bers. The general public can learn more about AHCA, read news updates pertaining to long-term care, and learn about upcoming events and conferences. The research and data section contains links to studies conducted on Medi-care/Medicaid, staffing, health care liability, surveys, state summaries, and links to data sources.

Gerontological Society of America

http://www.geron.org/

The Gerontological Society of America (GSA) is a non-profit professional organization dedicated to promoting the conduct of multi- and interdisciplinary research in aging and to disseminating gerontological research knowledge to researchers, practitioners, and decision and opinion mak-ers. Their website provides information about the organiza-tion as well as the ability to search their journals. There is a section listing grant and research opportunities in aging.

This list of resources was developed February, 2004, by the Institute for the Advancement of Social Work Research, Rebecca Toni, MSW Intern, [email protected], www.iaswresearch.org


Joint Commission on Accreditation of Healthcare Organizations

http://www.jcaho.org/

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits more than 15,000 health care organizations and programs in the Unit-ed States. It is the nation’s predominant standards-setting and accrediting body in health care. Their website provides some consumer and professional resources such as Quality Check. There are also links to resources and educational opportunities. Details about online seminars and other events and programs can be found online.

National Citizen’s Coalition for Nursing Home Reform

http://www.nccnhr.org

The National Citizens Coalition for Nursing Home Re-form (NCCNHR) is a group of consumers and advocates who define and achieve quality for people with long-term care needs. This is accomplished through informed, empow-ered consumers, effective citizen groups and ombudsman programs, promoting best practices in care delivery, public policy being responsive to consumer needs, and enforce-ment for consumer-directed living standards. NCCNHR’s website provides a wealth of resources including consumer and family information about choosing a nursing home, learning about Medicare’s prescription drug program, or knowing about residents’ rights. There are also resources for ombudsmen, updated fact sheets, detailed information about government policy, and online access to their news-letter and other reports and publications.

Pioneer Network

http://www.pioneernetwork.net

The Pioneer Network advocates and facilitates deep sys-tem change and transformation in the culture of aging. To achieve this, they create communication, networking, and learning opportunities, build and support relationships and community, identify and promote transformations in practice, services, public policy and research, and develop and provide access to resources and leadership. Their web-site accomplishes these aims by providing a discussion board, job postings, and an event calendar. There are also links to resources such as publications, research, and an online store.

Federal Agencies and Resources

Administration on Aging

http://www.aoa.gov/

The Administration on Aging’s (AoA) mission is to pro-mote the dignity and independence of older people, and to help society prepare for an aging population. Their website contains resources for the elderly and their families such as an Alzheimer’s resource room and elder rights resources. Information for professionals includes resources about ad-dressing diversity and statistical information. There is also information about AoA’s grant program and funding op-portunities.

Agency for Healthcare Research and Quality (AHRQ)

http://www.ahrq.gov/

The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficien-cy, and effectiveness of health care for all Americans. Their website provides information divided for consumers and patients, including clinical information, funding opportu-nities and data, and surveys. There are also links to specific research findings, media resources, and quality assessment tools such as the National Quality Measures Clearinghouse and the Consumer Assessment of Health Plans (CAHPS).

Centers for Medicare and Medicaid Services

http://www.cms.hhs.gov

The Centers for Medicare and Medicaid Services (CMS) seeks to assure health care security for beneficiaries.

CMS Guidance to State Survey Agency Directors and CMS Regional Offices

http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp

CMS memoranda, letters, and instructions to State Survey Agency Directors and CMS Regional Offices are posted here by category.

CMS MDS 3.0

http://www.cms.hhs.gov/quality/mds30/

The information posted on this site is intended to assist nursing homes, state agencies, software vendors, professional associations, and other federal agencies in the activities underway to refine and evaluate the MDS. It includes a section for providing feedback and other materials for public comment.


CMS Nursing Home Quality Initiative

http://www.cms.hhs.gov/quality/nhqi/

Provides links to information specific to nursing home quality initiatives. There are also links to informa-tion about quality measures, information about choos-ing a nursing home, and links to the nursing home compare website.

CMS Open Door Forum on Skilled Nursing Facilities and Long-Term Care

http://www.cms.hhs.gov/opendoor/snf-ltc.asp

These forums address the concerns and issues of the Medicare SNF, the Medicaid NF, and the long-term care industry generally, including the Long-Term Care Hospital PPS. The types of issues that come up during these forums are often related to the Minimum Data Set, SNF Consolidated Billing, the roles and responsi-bilities of different SNF, NF or LTC professional staff under CMS regulations, clarifications of issues that are covered during a survey and certification process, and the many rules and requirements under which different related services can be payable. Links to information about schedules and registration are found here as well.

CMS Quality Initiatives

http://www.cms.hhs.gov/quality

This page provides links to a few of CMS’ various quality improvement efforts. This includes information about quality initiatives in general and links to data col-lection such as MDS 3.0.

CMS State Operations Manual Appendices

http://www.cms.hhs.gov/manuals/107_som/som107_appendixtoc.asp

This page contains links to documents found in the appendix of the State Operations Manual. These docu-ments give specific guidance for issues such as providing intermediate care to persons with mental retardation or interpretive guidelines for long-term care facilities.

Nursing Home Compare

http://www.medicare.gov/nhcompare

This site allows consumers and professionals to learn about the past performance of every Medicare- and Medicaid-certified nursing home in the coun-try. Nursing homes can be searched by geography, proximity, or name.

Department of Veterans Affairs

http://www.va.gov/

The goal of the Department of Veterans Affairs (VA) is to provide excellence in patient care, veteran benefits, and customer satisfaction.

Patient Education and Family Materials

http://www1.va.gov/GeriatricsSHG/page.cfm?pg=27

This website provides links to more specific in-formation for patients and families. This information spans topics such as the role of the caregiver, working with bureaucracies, aggressive behavior, and financial and legal advice.

VA Social Work

http://www1.va.gov/socialwork/

This site has information for veterans, their fami-lies, the public, social work students, and prospective employees. It contains general information about what social workers do and how to contact a VA social worker. There are also links to social work resources and infor-mation about educational opportunities at the VA for students.

Veterans Health AdministrationGeriatrics and Extended Care Strategic Healthcare Group

http://www1.va.gov/geriatricsshg/

The Geriatrics and Extended Care Strategic Health-care Group advances quality care for aging and chroni-cally ill veterans by providing policy direction for the development, coordination, and integration of geri-atrics and long-term care clinical programs. This site provides links to their various programs such as home and community based long-term care, VA nursing home care, and hospice and palliative care. They also provide a VA facility locator search engine, links to handbooks and directives, and a schedule of upcoming educational events.

National Institute on Aging

http://www.nia.nih.gov

The National Institute on Aging’s (NIA) mission is to improve the health and well-being of older Americans by supporting and conducting research, training research-ers, developing resources, and disseminating information. Their website contains links to publications and informa-tion about research sponsored by and conducted at NIA. It also contains a link to the NIH Senior Health site, which


is oriented toward seniors and has information addressing various health concerns. There are also links to informa-tion about grant and training opportunities.

National Institute of Mental Health

http://www.nimh.nih.gov

The mission of the National Institute of Mental Health (NIMH) is to reduce the burden of mental illness and be-havioral disorders through research on mind, brain, and behavior. Their website provides links to news, research findings, health information, and funding opportunities.

Geriatrics Research Branch

http://www.nimh.nih.gov/datr/a4-gp.cfm

The Geriatrics Research Branch supports programs of research, research training, and resource development in the etiology and pathophysiology of mental disorders of late life, the treatment and recovery of persons with these disorders, and the prevention of these disorders and their consequences. Their site provides links to information about the various branch programs subsumed in this divi-sion.

Office of Inspector General, Department of Health and Human Services

Report: Psychosocial Services in Skilled Nursing Facilities

http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf

This website links to a pdf file containing the complete OIG report.

Social Work Organizations

Council on Social Work Education

http://www.cswe.org

The Council on Social Work Education (CSWE) is a national association that preserves and enhances the qual-ity of social work education for practice that promotes the goals of individual and community well-being and social justice. Their website provides access to various resources including publications and social work links. The website also offers access to information about their various proj-ects and programs such as SAGE-SW and the Gero-Ed Center.

Hartford Geriatric Social Work Initiative

http://www.gswi.org

The Geriatric Social Work Initiative site provides infor-mation about the many resources available to social work-ers in geriatrics. It lists funding opportunities, educational resources, job opportunities, upcoming events, scholarship opportunities, and detailed links and information for new researchers.


http://www.iaswresearch.org/

The Institute for the Advancement of Social Work Re-search (IASWR) strives to strengthen the connections be-tween research and policy and practice, build the research capacity of the profession, and advance the knowledge base through social work research. The website will provide ac-cess to information from the conference such as these web resources and the information contained in the briefing book. It also provides access to various publications, links to resources and information, about funding opportunities.

Institute for Geriatric Social Work—Boston University

http://www.bu.edu/igsw/index.html

The Institute for Geriatric Social Work is dedicated to advancing social work practice with older adults and their families. Their website provides access to information about training and educational opportunities. This includes in-formation about their small-grants program and distance-learning courses. They also provide access to publications, information about research and advocacy opportunities, and links to related information sources.

National Association of Social Workers

http://www.socialworkers.org

The National Association of Social Workers (NASW) is a membership organization of professional social workers. NASW works to enhance the professional growth and de-velopment of its members, to create and maintain profes-sional standards, and to advance sound social policies.

NASW Clinical Indicators for Social Work and Psychosocial Services in Nursing Homes

http://www.socialworkers.org/practice/standards/nursing_homes.asp

This site connects to an online publication of Clini-cal Indicators for Social Work and Psychosocial Services


in Nursing Homes. The clinical indicators are divided into process and outcome indicators. Process indicators include timely psychosocial assessment, comprehensive psychosocial assessment, resident involvement in care planning, and family involvement in care planning. Outcome indicators include resident satisfaction with choice and problem resolution.

NASW Standards for Social Work Services in Long-Term Care Facilities.

http://www.socialworkers.org/practice/standards/NASWLongTermStandards.pdf

This site connects to a pdf. file containing this pub-lication. The document details 11 standards such as ethics and values, staffing, professional development, documentation, and cultural competence.

Society for Social Work and Research

http://www.sswr.org

The Society for Social Work and Research is a profes-sional membership organization dedicated to advancing so-cial work research and to assisting novice and experienced researchers in a variety of ways. Their website provides in-formation about their annual conference, award opportu-nities, and provides membership-specific areas. There are also links to relevant websites and job postings.

The mission of the Institute for the Advancement of Social Work Research (IASWR) is to advance the scientific knowledge base of social work practice by enhancing the research capacity of the profession; to promote the use of research to improve practice, program development and policy; to strengthen the voice of the profession in public education and public policy determinations by ensuring that social work is represented within the national scientific community. IASWR fulfills this mission through expanding opportunities for social work research, preparing social work researchers, disseminating findings to inform policy, representing the profession in scientific and policy communities, and establishing linkages with other related disciplines.

INSTITUTE FOR THE

ADVANCEMENT OF

SOCIAL WORK RESEARCH

Documents

Evaluating Social Work Services in Nursing Homes: Toward Quality